Aristotle once said that “the guest is a better judge of the feast than the cook. (1)” Since his time social psychological research has shown that viewing oneself through another’s lens is an invaluable assessment tool (2). Following this principle, Americans should look to other countries to gain clues as to where our health policy problems lie. In 2005, some American college students asked a sampling of Australians what they thought of Americans. The Australian’s answers fell into three categories: arrogant, stupid, and fat (2). This video is not the only indication of our poor public appearance; indeed, these descriptors turn 40,000 Google search results ranging from fallible blogs to news articles citing the United States government reports (3).

While arrogance is an arbitrarily defined characteristic, education and obesity levels are quantifiably measured and compared. The American military recently corroborated the assertion that Americans are unintelligent and overweight. This report estimates that up to 75% of 17-24 year old Americans are ineligible for military service, despite recently relaxed enlistment requirements (4). These deferrals are primarily due to educational limitations and physical issues, primarily obesity (5).

This high proportion of weight based rejections is to be expected, after all, obesity rates have steadily climbed since the 1970’s (6). Fortunately this obesity epidemic has plateaued during the past five years (7). Recent reports establish that American obesity rates have leveled at 32.2% of men and 35.5% of women (8). Unfortunately this stagnation may be indicative of a saturation point and not a move toward better eating and exercise habits (7). Other sources indicate that these rates are still climbing and may reach 40% by 2018 (9). Regardless of whether the rates are increasing or leveling, they do not show a decrease. It is imperative that the United States reverse these trends as obesity is causally linked to many health-care intensive conditions, including heart failure, diabetes, stroke, and psychological distress (10).

When we examine the “stupid” part of the conjecture, we find that consumers are in an untenable situation. First, the American public school system does not ensure that people possess the reading comprehensive levels required to successfully navigate the health care system (11). Second, the medical system is rife with bureaucratic red-tape. A Journal of General Internal Medicine report found that comprehending the legislation set to protect patient rights requires two years of college level reading (10). To put this in perspective, approximately 70% of the United States population over the age of 25 cannot understand the laws which govern their health care rights (11). This ambiguity has created a market of confused individuals who receive substandard care while being melded into padding the bottom line for insurance companies (15). Current legislation proposals do little to simplify this language and often lead to increased confusion (12).

These two issues are obviously complex and change will require legislative action coupled with personal initiative. In regard to obesity, law makers can impose “sin taxes” on items which are high in calories and low in nutritional value, such as soda and candy, to discourage their consumption. This approach has shown positive results in the tobacco industry and shows promise for junk food items (12). Furthermore, fast-food chains should be required to post calorie and fat content on their menus. Studies have shown that while this does not decreased the number of calories adults consume, it has led to parents to make healthier decisions for their children (17). Hopefully, with targeted advertisements, adults also will make healthier decisions for themselves.

Yet these measures will likely fail without building a supporting infrastructure through public educational changes. If the public school systems limit their menus to wholesome, palatable options, children will learn from an early age what foods are wholesome. Additionally, candy and soda should be eliminated from schools. Often junk food vendors provide schools with funding to peddle their products. By legislatively eliminating this perverse incentive, children will be pushed to choose healthy options (18). These legislative changes coupled with increased nutritional education and physical activity will instill healthy values in our children.

Americans must take personal responsibility for our bodies and change our eating and exercise habits instead of making excuses. Experts show that only 2% of individuals become obese as a result of underlying metabolic disorders, a fact which renders the “it’s genetic” excuse a moot point (14). If we spent more time cooking for ourselves instead of watching cooking shows, our eating habits would significantly improve (13).

In regard to health systems comprehension, the government must require health insurers and providers to communicate effectively. Admittedly, the health system is not responsible for the population’s reading abilities; but they are responsible to meet the needs of their clients (10). This means that insurers and providers must provide culturally competent information to their patients at a reading level they comprehend. Some insurers have successfully implanted “words we use” lists in their call centers to translate the complicated jargon (22). If organizations were required to utilize these words and provide all materials at an 8th grade reading level, comprehension and compliance would increase (12).

Finally, on a personal level, we must increase our involvement in our own health care. We, the patients, must educate ourselves concerning our conditions and treatment options. This will allow us to maximize the time we spend with our physicians and ensure appropriate treatment.

If we couple legislative changes with personal agency to our food delivery system and health systems comprehension we can slow and prevent future ill-health. By making these changes, hopefully the next five years will lead to Americans being known as something besides stupid and fat. After all, our health, and national reputation, depend on it.

Unlike most twenty-three-year-old sorority alumnae, I receive my monthly subscription of Cosmo with a side of insurance rejections: such is the life of a coed who lost the genetic lottery. Thankfully, I earned an undergraduate degree in Health Administration and specialize in reminding health care organizations of their contractual obligations. Unfortunately the majority of Americans have not had this training while the red tape surrounding the insurance system is dense and misleading (1). But that’s to be expected; even the laws put in place to protect patient rights are incomprehensible. A Journal of General Internal Medicine report found that legislation set to protect patient rights is comprehensible to people with a reading level equivalent to that of an Associate Degree (2). To put this in perspective, approximately 70% of the United States population over the age of 25 can’t understand the laws which protect their health care rights (3). This ambiguity has created a market of confused individuals who are easily melded into padding the bottom line for both insurance companies and for-profit health care advocates.

According to the California Nurses Association, 1 in 5 claims are rejected by private insurance companies each year (4). These rejections can occur before or after care is received and come in two classes: quantitative and subjective. The first genre consists of clerical errors and miscoding issues, both of which are easily corrected to the subscribers benefit (so long as the subscriber catches the error, knows their benefits, and appeals the rejection in a timely manner). The second groups of denials are difficult to negotiate as they result the insurance companies definition of preexisting conditions, medical necessity and experimental procedures (5).

Comedian Stephen Colbert illustrated the satirical nature of this licensure in his October 29, 2009 introduction in which he asked “What qualifies as a preexisting condition? … If you have to ask, you probably have one! (6)” Take for example Stephanie, a 24 year old from Oakland, California, who opted into a single-payer insurance policy while she was studying for her MCATs. She went to the doctor for an annual exam and was diagnosed with bronchitis. This diagnosis led her insurance company to do a five-year review of her medical records in which they found evidence of a past chest infection, providing them with grounds to refuse payment for her care. She never thought that her former chest cold could be a preexisting condition, yet due to her insurance company’s interpretation, she was forced to pay out of pocket (7). Obviously the insurance industry has to stack the deck in their favor; they are for-profit companies and deserve to be compensated for their sizeable gamble on individuals, but the high profits which result from rising premiums and unclear coverage denials is unethical (8).

This no-man’s land between insurers and individuals has led to a job market in patient advocacy. Many advocacy groups are either non-profit or governmental agencies; indeed, most states have patient advocacy bureaus to help their residents navigate the difficult legislature governing their care (9). Unfortunately these bureaus, like most social service sectors, are overworked and underpaid, forcing states to mandate who qualifies for advocacy (10). This urges patients with financial means to employ private, for-profit advocacy agencies to help them navigate the intricacies of the health care system, adding additional cost to their health care. Furthermore, the for-profit nature of these companies caters to healthy individuals, and some refuse to work for people with preexisting conditions, leaving those who desperately need support without recourse (11).

Einstein once said “make everything as simple as it has to be, but no simpler.” If this principle governed the success of Time’s “Person of the Century,” perhaps we should consider applying his wisdom to our current health care crisis (13). Simplicity is indeed the key to our success. Currently, health care reform bills have provisions to subsidize and reward the utilization of electronic medical records. Unfortunately, these electronic medical records are not currently at a developmental level which would supply security or uniformity. Yet these systems have great promise, indeed, if they are streamlined, continuity and accuracy of care would be vastly improved (14). A standardized record system would incite uniform regulations across insurers, helping to hold the insurance system accountable in a laissez-faire manner which increases its political viability. Furthermore, the clarity this system provides would help subscribers to understand the reasoning behind decisions which were formerly illogical. Unfortunately this goal is several years in the offing and we cannot wait to provide culturally relevant data to patients.

I recently attended a Comparative Effectiveness Research seminar in which Dr. Robert Epstein was panel member; I recognized his name, but couldn’t immediately place him (12). Halfway through the panel, it hit me - Epstein’s signature is affixed to letters I receive from Medco Health Solutions when my prescription drug coverage changes. In my world, Epstein is the prescription-drug-coverage-devil. But as I sat listening to his speech on personalized medicine, his congenial nature and “carpe diem” philosophy made me realize that the man behind the signature is human and truly cares for his subscriber’s futures.

Insurance companies are made up of educated people who, like Epstein, want what’s best for their subscribers. Admittedly, the more effective treatments are, the less they have to pay in the future. Yet these companies are woefully unsuccessful and demonized by the lay public in their attempts at efficiency. Likewise, the current push for health care reform is misunderstood and chaos abounds. If you want proof that a number of Americans do not understand the goals of health reform, look no further than “end of life counseling” being touted as “death panels.” Something has been lost in translation. If our goal is efficient, culturally competent care, the information delivery system must be clarified and translated via an appropriate advocate.

Note: For this piece I was recognized in NCHE's Annual Scholarship competition.